Infectious and thrombotic complications of central venous catheters

Outcomes of Port A Catheter Implantations in Cancer Patients: Experience in 102 Cases

Aim

This study evaluates cancer patients undergoing port catheter implantation.

Patients and methods

The study was conducted among patients admitted to the cardiovascular department of Düzce State Hospital from June 2018 to July 2020. The inclusion criterion was the implantation of a vascular port for at during 2 years. One hundred and two patients were enrolled in the study. The most common acute outcomes such as pneumothorax, haemothorax, thoracic duct damage and cardiac tamponade and the demographic characteristics of all patients were recorded. Patients were evaluated for the late complications of port catheter, such as thrombosis, infection and kinking, catheter fracture and occlusion.

Results

Complications of port catheter occurred early (≤30 days) and delayed (>30 days) at rates of up to 8% and 15%, respectively. The most common early and late complications were pneumothorax and non-functional port (occlusion, thrombosis, kinking), respectively.

Conclusions

Thrombosis is the most common cause of dysfunction in central port catheters used in the treatment of cancer patients. Routine radiological imaging can help in early detection of catheter-related complications.

Nitric Oxide-Releasing Lock Solution for the Prevention of Catheter-Related Infection and Thrombosis

Although frequently used, venous catheters are often associated with serious complications such as infection and thrombosis. Lock solution therapies are clinically used to deter these issues but generally address only infection or thrombosis with limited success. Here, we report the development of a dual-functional lock therapy using nitric oxide (NO) donor molecule, S-nitrosoglutathione (GSNO). NO is a potent, broad-spectrum antimicrobial agent that also temporarily inhibits platelet activation, preventing thrombosis. Furthermore, NO has antibiofilm actions, an ability that traditional antibiotic lock solutions lack, thus limiting their efficacy. In this work, different concentrations of GSNO were characterized via NO analysis to determine a range of NO-releasing lock solution (NOreLS) concentrations to investigate and to demonstrate prolonged potential efficacy. Tested against clinically used vancomycin and gentamicin lock solutions, GSNO-based NOreLS repeatedly outperformed in models of different stages of catheter infections. NOreLS also prevented clot formation when exposed to whole blood, showing increased efficacy compared to a heparin lock solution. Moreover, NOreLS was demonstrated to be biocompatible via hemolysis and cytotoxicity assays. NOreLS has excellent potential for safely and effectively preventing infection and thrombosis related to catheter usage.

Securement of central venous catheters by subcutaneously anchored suturless devices in neonates

BACKGROUND

Accidental dislodgement of central venous catheters is a frequent complication in NICU and it often requires catheter replacement. Subcutaneously anchored sutureless devices (SAS) have been recently introduced in clinical practice for securement of different types of central catheters, but they have never been used in neonates. We evaluated safety and efficacy of SAS in neonates.

METHODS

All neonates who required central venous catheters inserted via ultrasound-guided cannulation during 12 months of clinical practice in our NICU. We adopted SAS for securement of all central venous catheters inserted in neonates via ultrasound guided cannulation either of the brachio-cephalic vein (centrally inserted central catheters: CICC) or the femoral vein (femorally inserted central catheters: FICC). Results: seventy-two central catheters were inserted in 70 preterm and term neonates (3-4 Fr power injectable polyurethane catheters; 62 CICC + 10 FICC) and they were all secured with SAS. Mean postmenstrual age at the time of insertion was 31 weeks and mean weight was 1400 g. SAS was easy to place in all cases. The median duration of the line was 6 weeks. No accidental dislodgement of CICC or FICC was recorded. All SAS but one were left in place until elective removal of the catheter. In all patients, SAS removal was easy and uneventful, and it did not require any sedation or local anesthesia. Conclusions: SAS was effective in preventing accidental catheter dislodgement in 100% of cases. Complications during insertion, maintenance and removal were negligible.

ACR Appropriateness Criteria® Radiologic Management of Central Venous Access

Obtaining central venous access is one of the most commonly performed procedures in hospital settings. Multiple devices such as peripherally inserted central venous catheters, tunneled central venous catheters (eg, Hohn catheter, Hickman catheter, C. R. Bard, Inc, Salt Lake City UT), and implantable ports are available for this purpose. The device selected for central venous access depends on the clinical indication, duration of the treatment, and associated comorbidities. It is important for health care providers to familiarize themselves with the types of central venous catheters available, including information about their indications, contraindications, and potential complications, especially the management of catheters in the setting of catheter-related bloodstream infections. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A community collaborative to develop consensus guidelines to standardize out-of-hospital maintenance care of central venous catheters

Central venous catheter (CVC) maintenance is integral to preventing complications and improving outcomes. This process is made more challenging when patients transition from hospital to home care or to an outpatient infusion setting, because different CVC maintenance practices and care parameters confuse patients and care providers alike. Through collaboration and consensus building, a group of metropolitan home health and home infusion agencies developed a standardized approach to CVC maintenance care. This article discusses the multiagency collaborative and resulting guideline and other educational materials that better enable providers, patients, and families to maintain CVC integrity and achieve optimal outcomes.

[Heparin for clearance of peripherally inserted central venous catheter in newborns: an in vitro study]

Objective:

To compare the efficacy of two concentrations of heparin to clear the lumen of in vitro clotted neonatal peripherally inserted central catheters (PICCs).

Methods:

This is an in vitro, experimental quantitative study of 76 neonatal 2.0-Fr PICCs coagulated in vitro. The catheters were divided into two groups of 38 PICCs each. In both groups an infusion of low molecular weight heparin was administered with a dose of 25IU/mL for Group 1 and 50IU/mL for Group 2. The negative pressure technique was applied to the catheters of both groups at 5, 15 and 30min and at 4h to test their permeability. Kaplan-Meier survival analysis was used to verify the outcome of the groups according to time intervals.

Results:

The comparison between both groups in the first 5min showed that more catheters from Group 2 were cleared compared to Group 1 (57.9 vs. 21.1%, respectively). Kaplan-Meier survival analysis showed that less time was needed to clear catheters treated with 50IU/mL of heparin (p<0.001).

Conclusions:

The use of low molecular weight heparin at a concentration of 50IU/mL was more effective in restoring the permeability of neonatal PICCs occluded in vitro by a clot, and the use of this concentration is within the safety margin indicated by scientific literature.

Feeling Confident in Using PICC Lines

Treatments involving chemotherapy require central venous access, such as a Peripherally Inserted Central (PICC) line. The aim of the study was to describe patients’ experiences of living with a PICC line during chemotherapy treatment. The study comprised interviews with 10 patients and was analyzed using manifest qualitative content analysis. The categories The importance of security, The importance of contentedness, and Feeling confident in using the PICC line were identified. To contribute to patient safety and empowerment in health care, nurses must be well trained in PICC line care. Therefore, evidence-based knowledge about central venous access is necessary for patients’ security and contentedness and to improve quality of care and increase patients’ well-being in central venous access care activities in the future.

Incidence of catheter-related complications in patients with central venous or hemodialysis catheters: a health care claims database analysis

Background

Central venous catheter (CVC) and hemodialysis (HD) catheter usage are associated with complications that occur during catheter insertion, dwell period, and removal. This study aims to identify and describe the incidence rates of catheter-related complications in a large patient population in a United States-based health care claims database after CVC or HD catheter placement.

Methods

Patients in the i3 InVision DataMart^® health care claims database with at least 1 CVC or HD catheter insertion claim were categorized into CVC or HD cohorts using diagnostic and procedural codes from the US Renal Data System, American College of Surgeons, and American Medical Association’s Physician Performance Measures. Catheter-related complications were identified using published diagnostic and procedural codes. Incidence rates (IRs)/1000 catheter-days were calculated for complications including catheter-related bloodstream infections (CRBSIs), thrombosis, embolism, intracranial hemorrhage (ICH), major bleeding (MB), and mechanical catheter–related complications (MCRCs).

Results

Thirty percent of the CVC cohort and 54% of the HD cohort had catheter placements lasting <90 days. Catheter-related complications occurred most often during the first 90 days of catheter placement. IRs were highest for CRBSIs in both cohorts (4.0 [95% CI, 3.7-4.3] and 5.1 [95% CI, 4.7-5.6], respectively). Other IRs in CVC and HD cohorts, respectively, were thrombosis, 1.3 and 0.8; MCRCs, 0.6 and 0.7; embolism, 0.4 and 0.5; MB, 0.1 and 0.3; and ICH, 0.1 in both cohorts. Patients with cancer at baseline had significantly higher IRs for CRBSIs and thrombosis than non-cancer patients. CVC or HD catheter–related complications were most frequently seen in patients 16 years or younger.

Conclusions

The risk of catheter-related complications is highest during the first 90 days of catheter placement in patients with CVCs and HD catheters and in younger patients (≤16 years of age) with HD catheters. Data provided in this study can be applied toward improving patient care.

Efficacy of ethanol against Candida albicans and Staphylococcus aureus polymicrobial biofilms

Candida albicans, an opportunistic fungus, and Staphylococcus aureus, a bacterial pathogen, are two clinically relevant biofilm-forming microbes responsible for a majority of catheter-related infections, with such infections often resulting in catheter loss and removal. Not only do these pathogens cause a substantial number of nosocomial infections independently, but also they are frequently found coexisting as polymicrobial biofilms on host and environmental surfaces. Antimicrobial lock therapy is a current strategy to sterilize infected catheters. However, the robustness of this technique against polymicrobial biofilms has remained largely untested. Due to its antimicrobial activity, safety, stability, and affordability, we tested the hypothesis that ethanol (EtOH) could serve as a potentially efficacious catheter lock solution against C. albicans and S. aureus biofilms. Therefore, we optimized the dose and time necessary to achieve killing of both monomicrobial and polymicrobial biofilms formed on polystyrene and silicone surfaces in a static microplate lock therapy model. Treatment with 30% EtOH for a minimum of 4 h was inhibitory for monomicrobial and polymicrobial biofilms, as evidenced by XTT {sodium 2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-5-[(phenylamino)carbonyl]-2H-tetrazolium hydroxide inner salt} metabolic activity assays and confocal microscopy. Experiments to determine the regrowth of microorganisms on silicone after EtOH treatment were also performed. Importantly, incubation with 30% EtOH for 4 h was sufficient to kill and inhibit the growth of C. albicans, while 50% EtOH was needed to completely inhibit the regrowth of S. aureus. In summary, we have systematically defined the dose and duration of EtOH treatment that are effective against and prevent regrowth of C. albicans and S. aureus monomicrobial and polymicrobial biofilms in an in vitro lock therapy model.

Accessing implanted ports: still a source of controversy

In delivering safe care to their patients, oncology nurses should be familiar with the proper use and maintenance of implanted ports. Yet, despite the ubiquitous presence of implanted ports, accessing techniques and patency maintenance remain controversial. Additional research is needed to establish practices based on evidence.

Evaluation of Radiologically Implanted Central Venous Port Systems Explanted Due to Complications

Purpose

The aim of this study was to evaluate explantations of central venous port systems that were implanted by interventional radiologists in cases where complications demanded the removal of the port device.

Methods

In this retrospective single-center study, explantation rates of central venous port catheter systems (CVPS) associated with complications were investigated over a 10-year period. All CVPS were implanted and explanted in our radiology department's interventional suite. Port catheter dysfunctions were divided into early and late complications, as well as into nonthrombotic and thrombotic events. Indications for implantation and explantation as well as clinical demographics were considered.

Results

One hundred and ninety-three CVPS were removed from 182 patients, due to complications. The total indwelling time of all CVPS was 55,132 catheter-days (mean 285.7; range 1–2,704). The most common diagnoses were gastrointestinal cancers 77 (39.9%) and hematological malignancies 32 (16.6%). Bloodstream infections 134 (69.4%) were the most common indication for the explantation procedure. These were followed by catheter-related thrombosis 28 (14.5%), nonthrombotic CVPS dysfunction 18 (9.3%), port pocket infections 9 (4.7%), and others 4 (2.1%). The highest percentages of explantations related to bloodstream infections were observed in patients with malabsorption (81.8%) and hematological malignancies (81.3%).

Conclusion

Bloodstream infections were the most common cause for port explantation, followed by catheter-related thrombosis. Complication-related explantations were mainly for late-onset complications. Prevention and management strategies should be applied regarding care and usage of port systems to reduce the rate of complication-related explantations.